Provider Demographics
NPI:1235209339
Name:WALTERS, JUDITH CHRISTINA
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:CHRISTINA
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38864 COUNTRY CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1025
Mailing Address - Country:US
Mailing Address - Phone:248-737-0388
Mailing Address - Fax:248-533-8095
Practice Address - Street 1:6346 ORCHARD LAKE RD
Practice Address - Street 2:STE. 12
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2326
Practice Address - Country:US
Practice Address - Phone:248-737-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006592103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F34933Medicare ID - Type UnspecifiedMEDICARE LEGACY PROVIDER
MI68-0-F3499Medicare UPIN